| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Support Professional #1, date-of-hire 6/7/23, did not have a Pennsylvania criminal history record check. Direct Support Professional #2, date-of-hire 6/25/23, did not have a Pennsylvania criminal history record check. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The HR Supervisor did the background check for Direct Support professional #1 and #2 on 9/20/2023. Attached. The two staff initially did the FBI Fingerprint since they were not resident in PA for 2 years. |
09/26/2023
| Not Implemented |
| 6400.71 | On 9/21/23, none of the home's phones included any emergency numbers posted on them or nearby. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The Emergency contact numbers were posted in the home on 9/22/2023. |
09/22/2023
| Not Implemented |
| 6400.151(a) | Direct Support Professional #3, date-of-hire is 10/20/22, did not have a physical examination prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Program specialist notified the Direct Support Professional #3 on 10/11/2023 to provide a copy of the physical done prior to hiring. Direct Support Professional #3 contacted Med Express and document will be available within 10 days. Expected by 10/25/2023. |
10/25/2023
| Not Implemented |
| 6400.151(c)(2) | Direct Support Professional #3, date-of-hire is 10/20/22, did not have a completed tuberculosis test with negative results prior to employment. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The Program specialist notified the Direct Support Professional #3 on 10/11/2023 to provide a copy of the Tuberculin test with a negative result done prior to hiring. Direct Support Professional #3 contacted Med Express and document will be available within 10 days. Expected by 10/25/2023. |
10/25/2023
| Not Implemented |
| 6400.216(a) | On 9/21/23, Individual #1's records were observed unsecured and in plain sight on the kitchen counter at 11:23 AM. | An individual's records shall be kept locked when unattended.
| The Home Supervisor purchased a storage cabinet on 10/12/2023. Receipt attached. Individual #1¿s records are now placed in the locked cabinet inside the home. |
10/12/2023
| Implemented |
| 6400.18(a)(5) | EIM Incident #: 9229469 for neglect was discovered on 6/8/23 at 8:00 AM and reported on 6/9/23 at 11:59 AM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| The Certified Investigator organized a training on 10/9/2023 to discuss ODP Incident Management Bulletin # 00-21-02 that defines reporting timelines for various categories of incidents. |
10/09/2023
| Implemented |
| 6400.18(a)(13) | EIM Incident #: 9214291 for a rights violation was discovered on 5/9/23 at 5:00 PM and reported on 5/12/23 at 1:38 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
A violation of individual rights. | The Certified Investigator organized a training on 10/9/2023 to discuss ODP Incident Management Bulletin # 00-21-02 that defines reporting timelines for various categories of incidents. |
10/09/2023
| Implemented |
| 6400.46(b) | Direct Support Professional #1 completed annual fire safety training on 7/29/22 and has not yet done so for 2023. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The CEO contacted the Hempfield Fire safety Department on 10/9/2023 to plan a ¿train the trainer¿ class for Solidarity Employee to serve as inhouse Fire safety trainer. In the interim, a Fire safety training will be conducted by an outside Fire Specialist on October 25, 2023. |
10/25/2023
| Implemented |
| 6400.51(b)(1) | Direct Support Professional #3, date of hire 10/20/22, did not have orientation training in community integration. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Direct Support Professional #3 was notified by HR Supervisor on 10/6/2023 to complete annual training to include community integration. |
12/31/2023
| Implemented |
| 6400.51(b)(5) | Direct Support Professional #3, date of hire is 10/20/22, did not have orientation training in individual-specific reviews of behavior support plans as well as individual plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | The Home Supervisor organized a training on Individual #1¿s ISP on 9/22/2023. |
09/22/2023
| Implemented |
| 6400.169(a) | Direct Support Professional #3 completed the online examination of their initial medication administration practicum on 10/14/22. However, Direct Support Professional #3 has not completed the required medication passing observations for full completion of their initial Department-approved medication administration course within the allotted time frames as outlined by the Department. Direct Support Professional #3 has been administering medications. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Direct support Professional #3 completed the initial Medication Administration face-face training and 4 observations prior to administering medications. CEO #4 who is ODP Medication Administration Trainer contacted ODP Medication Administration Help desk on 10/9/2023 for clarification. Response will be submitted as an attachment. |
10/09/2023
| Implemented |